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I would start applying to ICU positions somewhere else. This unit is very toxic and you won't be able to change it, so get out with your sanity intact. Good luck!

If you are just looking to buy the patient some time until you can get an IABP, an inodilator like dobutamine might help. The thing is to figure out what is going to be done longterm, like is the patient getting valve surgery or a LVAD.

We use mittens for ventilator patients (which in our hospital are not considered restraints), and they work pretty well. If the patient is appropriately sedated usually there is no need for restraints, and the majority of our patients can be coached/reassured during sedation vacation and don't need to be restrained at all beyond just the mittens. On a few occasions we have used wrist restraints, but it's very rare maybe twice this year.

I would answer questions in a general sense if it came up, or recommend they discuss it with their provider but would never suggest any specific brand to patients be it generic or proprietary.

I recommend The ICU Book by Marino and The Ventilator Book by Owens

Yes, true, but a pH of 7.20 requires an intervention unless it's trending up? As for bicarb administration, I still see it used in cases of NAG metabolic acidosis and don't think it's going away.

I don't have an issue with it if it's for a respiratory procedure and the physician is at bedside. In practice, however, if it's my patient you better believe I'm the one pushing it!

The only logical explanations I can come up with is that you are either consistently bypassing the scanning step to clear the task before you actually pull the med, that you are scanning some sort of label instead of the actual medication, or that you consistently scanned leftover meds that were not wasted. I apologize for my bluntness but I do not believe that you do not know how this could happen for a total of five times. I'd also like to add that you could be easily recognized from the information you have given and should act with caution on this, and for your sake OP I hope it was not narcotics :/

Colleagues have provided very good information on this. To follow up on PressG33's comments, CPAP is generally used for people with OSA. Not only does it provide a continuous positive pressure (like PEEP but we don't call it that if we are talking about non-invasive pressure support ventilation) which helps with oxygenation, but most importantly it opens the airways by increasing intrathoracic pressure and pushes the tongue forward which is of great help for those who have OSA. With CPAP, it doesn't matter how fast the patient is breathing or if they stop breathing, it will deliver that pressure all the time. Bipap will deliver a different pressure depending on whether the patient is inhaling or exhaling. The pressure it gives when the patient is taking a breath is the inspiratory positive airway pressure IPAP, and expiratory positive airway pressure EPAP, when the patient breathes out. So, in a way it is like an assist mode on a ventilator with a set PEEP (would be the EPAP), and a pressure support (IPAP).

"Less stressful" This part made me laugh, haha MICU patients tend to be older with multiple comorbidities, while SICU varies but can have more of a mix or even a higher number of comparatively younger patients. In MICU you will see very sick patients, mostly infections, multiple organ failure, and pulmonary issues. As others have mentioned MICU patients tend to stay longer, some might be comatose so get ready for issues of futility and end of life. Not to say it is not an issue in the SICU, so be warned if you think it can be a problem for you. SICU patients that are younger tend to have a good chance to make it out of the unit, which can be emotionally rewarding. However, these are only generalizations and both are demanding and high stress. ICUs tend to attract interesting personalities, so the most important thing is to be proactive and enthusiastic about learning, as well as willing to become competent in your role. I won't lie the environment can be cut-throat so if you would like to work in a more relaxed environment, critical care might not be the right fit for you.

Hi there, Sorry to hear that you are going through a difficult time. I've been in the ICU less than two years, so kinda new myself. I can share what helped me when I was starting out, and maybe some of it can make this transition easier for you. What helped me the most as a new RN in the ICU was to get organized into a sort of tentative routine for the work day. Right after getting report I'd go assess my patients and see if there was anything urgent that needed to be done like drips running out or whatnot. If not I moved on to looking at their labs, X-rays, pending procedures, am meds, reading last progress notes from physicians, and just getting an overall idea of why the patients were in the ICU and their clinical situation. After that I'd get all the charting and assessment documentation done. By this time it'd be around 8-8:30am. If my patients had a diet I'd help them with am care and getting OOB to chair (unless I needed help from PT for that) and pass their their breakfast tray. For vented patients, do oral care and tidy up patient and room. Once this was done I'd pull up all the routine meds and by 9:30am I'd usually be done with that. The rest of the day would follow kind of the same structure, trying to stay flexible and adjust during the day. The most important thing I feel is to form a plan of care for the day that works for you, always doing everything ahead of time and taking at least thirty minutes early during your shift to look at the labs and read notes to see what's going on with your patient and what you can do during your shift to move the plan of care ahead. The second piece of advice I can give you is to read and study on your own when you get home, even if it's just an hour every night. You can get better at nursing skills just by observing your fellow experienced nurses and having the opportunity to practice them yourself with patients as time goes on. However, it takes a little more extra effort to learn about pathophysiology and disease process and that is something that you will mostly need to do independently. Make note of the most common conditions you see in your ICU (I know, mine also feels like a step down or LTAC most of the time) and research them. Little by little you will start feeling more confident as your knowledge base grows, and this should translate into ease of communication with colleagues and physicians. So, sorry about the long post but don't feel discouraged! It is a rite of passage of sorts, but the ICU is a very stimulating environment that will open many doors for you in the future.

I mean it all depends on the severity of the condition. Pulmonary edema, pneumothorax, pneumonia, ARDS can all cause serious problems with lung compliance. I'd say the worst case of noncompliant lung I've seen was a severe ARDS case. ARDS is like the lungs turning into concrete so imagine trying to ventilate that! Obstructions bring more of a problem with airway resistance, where you can't ventilate properly because the airway is obstructed with secretions, mucus plug, ET tube tip occluded or you are dealing with bronchospasm. In these situations you would be able to ventilate properly if the obstruction was removed, but the lung itself is compliant.

OK I think there's a few different things we should consider. OP states that the renal function appeared normal with BUN/creat in range. The patient is in severe respiratory acidosis, which cannot be expected to be compensated by the kidneys to any meaningful extent. The kidneys would take a long time to be able to compensate for such respiratory acidosis, if at all. The reason I asked about sedation and rate on the vent is that the pCO2 could in theory be lowered some with higher rates on the vent if the patient is so sedated that they are not triggering breaths. Even if the patient is in ARDS and you want to go for low tidal volumes, there is still some room there to increase the volumes a bit and it would all depend on how bad the ARDS was and the pressures the patient was doing. There are two things that affect your CO2 on a vented patient, and those are tidal volumes and rate and dialysis is not going to solve this particular problem. The second line of thinking has to do with the patient volume status. It is possible that this patient was in severe multiple organ failure/septic shock and was not making urine due to the fact that there was very little perfusion to the kidneys or as compensation for the patient fluid status. How much fluid was this patient getting, was the patient on vasopressors? As for dialysis, it is not clear from the information given that this patient had an indication for it. I know there is some debate regarding how soon to start RRT, but generally the indication for any type of dialysis would be related to an acute fall in GFR or that the patient has/is at risk for developing solute imbalance or volume overload, as in acute pulmonary edema resistant to diuretics, hyperkalemia and metabolic acidosis that are refractory to medical management, or removal of toxic substances that can be dialyzed such as salicylates. Yes, the patient's bicarb is slightly on the lower end but usually a bicarb of 18 does not warrant a bicarb drip, especially since it could make the respiratory acidosis worse. I feel that the main problem with this patient had to do with vent management.

Why was the patient hypotensive? Was this a MODS patient, volume down? Was the patient paralyzed? How much sedation was the patient on and what was the patient RR or vent rate? And no, the patient being anuric for 24 hours is not an indication for immediately starting dialysis. What was the renal function like? Did the patient not respond to other methods to diurese such as albumin/lasix etc?

I get what you mean, but diminished breath sounds are abnormal breath sounds. Let's say a patient has clear lung sounds to the upper fields/lobes but diminished to the bases bilaterally, then that's what you would say clear to upper fields but diminished to bases. If the patient has diminished sounds to all fields, then the lung sounds are diminished. There's no need to say clear and diminished, I think. In the absence of any other adventitious sounds to the area/s in question, if the only issue is that there's less flow, then when you say diminished it implies that it is "clear" of any consolidation/fluid/bronchoconstriction since there's no rhonchi/crackles/wheezing but there's just decreased flow to the area.